Clinic Onboarding Qualification
Please complete all sections to help us assess your clinic's onboarding eligibility.
Clinic Information
Clinic Name
Primary Contact Name & Title
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
How did you hear about us?
Clinic Type & Licensing
Clinic Type
Telehealth
Medical Spa
Physician Office
Other
Clinic Type - Other (please specify)
Licensed Prescriber on Staff?
Yes
No
Practice Scope & Location
Current Patient Volume (Monthly)
1–50
50–200
200–500
500+
States you are licensed in
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Product & Pharmacy Details
Products of Interest
GLP-1 (Semaglutide / Tirzepatide)
Peptides
Both
Current Pharmacy or Pharmacies (if applicable)
Are you currently experiencing issues with your pharmacy?
Yes
No
If yes, briefly explain
Volume, Compliance & Timeline
Estimated Monthly Order Volume
Low (<$5k)
Medium ($5k–$25k)
High ($25k+)
Do you agree to submit valid prescriptions and follow state regulations?
Yes
No
Timeline to Start
Immediately
Within 30 days
Just Exploring
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